Narrow Results Clear All
- WebM&M Cases 1
- Perspectives on Safety 6
- Review 4
- Study 7
- Audiovisual 21
- Book/Report 5
- Legislation/Regulation 1
- Newspaper/Magazine Article 101
- Newsletter/Journal 1
- Special or Theme Issue 2
- Web Resource 5
- Award 1
- Press Release/Announcement 1
- Communication Improvement 6
- Culture of Safety 8
Education and Training
- Students 1
- Error Reporting and Analysis 29
- Human Factors Engineering 5
- Legal and Policy Approaches
- Logistical Approaches 4
- Quality Improvement Strategies 15
- Teamwork 1
- Technologic Approaches 10
- Transparency and Accountability 2
- Device-related Complications 2
- Diagnostic Errors 21
- Discontinuities, Gaps, and Hand-Off Problems 10
- Drug shortages 4
- Fatigue and Sleep Deprivation 4
- Identification Errors 2
- Medical Complications 18
- Medication Errors/Preventable Adverse Drug Events 13
- Overtreatment 1
- Psychological and Social Complications 8
- Surgical Complications 20
- Internal Medicine 52
- Nursing 5
- Pharmacy 6
- Family Members and Caregivers 4
- Health Care Executives and Administrators 39
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 5
- Patients 120
Search results for "Legal and Policy Approaches"
- Legal and Policy Approaches
- Role of the Media
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
Web Resource > Multi-use Website
ProPublica, Inc. New York, NY.
Ghaferi AA, Myers C, Sutcliffe KM, Pronovost PJ. Harv Bus Rev. July/August 2016;94.
Achieving high reliability is a recognized goal for health care organizations. Reviewing current technical and standardization enhancements to augment quality and safety in surgery, this article explores how implementing high reliability concepts could further improve safety in surgical care over time.
Rau J. National Public Radio. July 27, 2016.
Although quality rating systems have yet to receive approval across the health care industry, they still serve as a way for consumers to select hospitals and providers. The developers of rating services continue to refine metrics to hone their effectiveness. This news article reports on the latest set of ratings from the Hospital Compare program and concerns associated with the results.
Frakt A. New York Times. July 11, 2016.
Patients are increasingly using online symptom checkers for medical information and health care recommendations. This newspaper article reports on various health information applications that provide triage advice to patients and points out that physicians have significantly lower rates of diagnostic errors.
Aleccia J. Seattle Times. June 18, 2016.
Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports on a patient who became engaged in working to redesign processes to improve patient safety after he became paralyzed from the chest down due to a cascade of communication errors.
Miller N. The Pathologist. June 2016(20):18-29; July 2016(21):18-33.
In light of the growing focus on diagnostic errors, this magazine series reports on unique challenges that pathologists face when they discover potential errors. The first article in the series discusses how pathologists may experience barriers to disclosure including feeling shame in disclosing their own error, discomfort with raising concerns about a colleague who has misdiagnosed a patient, and lack of direct relationships with patients. The second article expands the discussion to focus on how industry support of open transparency can enable pathologists to participate in reporting and disclosure activities.
Robbins A. Good Housekeeping. May 20, 2016.
Disruptive behaviors are receiving increased attention as a cultural factor that contributes to medical error. Although much of the focus has been on physicians, the presence of bullying among nurses is also a concern. This magazine article explores nurse behaviors such as withholding information, intimidation, and name calling that negatively affect patient safety and nurse retention.
Rau J. Washington Post. May 17, 2016.
Collecting data to meet quality measurement requirements adds to resource burden for many health care organizations, and there is controversy around the benefits of such rating systems for both patients and clinicians. This news article discusses problems with the Centers for Medicare and Medicaid Services rating mechanism, Hospital Compare.
Landro L. Wall Street Journal. May 9, 2016.
Closed claims have been considered a source for adverse event data for years, and recently such data has been utilized to inform safety improvement work. This newspaper article reviews several organizational efforts that use claims data to determine factors that contribute to failure and strategies to address them, including process redesign and enhanced patient education.
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
Journal Article > Study
Lagu T, Goff SL, Craft B, et al. J Hosp Med. 2016;11:52-55.
Researchers in this study reviewed patient feedback posted on a hospital's Facebook page to determine whether social media may be a helpful mechanism for identifying patient safety and quality improvement issues. In this small sample of 37 respondents over a 3-week period, insights from social media comments did not seem to add much to the feedback already collected by more traditional methods, such as patient satisfaction surveys.
Journal Article > Review
Systematic review on the prevalence, frequency and comparative value of adverse events data in social media.
Golder S, Norman G, Loke YK. Br J Clin Pharmacol. 2015;80:878-888.
Medication errors are common in the outpatient setting and frequently lead to emergency department visits and hospital admissions. The growth in social media use potentially provides a way to identify safety hazards quickly. This systematic review sought to examine whether social media could provide unique insights into safety issues compared to standard methods of detecting safety hazards. The included studies searched a variety of social media sites (e.g., Twitter, YouTube, and discussion forums) and found that a large number of adverse events are discussed in real time. Most of these events tended to be mild, such as symptoms or asymptomatic lab test abnormalities. Serious adverse events, those requiring urgent treatment or hospitalization, were relatively underrepresented. Although searching social media may help identify unique safety hazards, the investigators concluded that current evidence is insufficient to determine whether routine analysis of social media is of added benefit to traditional surveillance methods.
Inside Canada's secret world of medical error: 'There is a lot of lying, there's a lot of cover-up.'
Blackwell T. National Post. January 16, 2015.
Koba M. Fortune. January 6, 2015.
Jaffe I, Renincasa R. Morning Edition. National Public Radio. December 8–9, 2014.
Overprescribing of medications is a common problem in nursing homes. This two-part radio segment reports on the inappropriate use of antipsychotic medications as a chemical restraint for patients with dementia. The first part introduces the issue and includes insights from families that have experienced harm due to the practice. The second segment discusses programs that the Centers for Medicare and Medicaid Services has put in place to address the problem through a more patient-centered approach to care and suggests strengthening penalties against organizations that overuse antipsychotics.
Dunklin R, Thompson S. Dallas Morning News. December 6, 2014.
This news article reports on the widely publicized delayed diagnosis of Ebola at a Dallas hospital and reveals previously undisclosed details from the emergency room physician who misdiagnosed the patient when he first presented, including information and communication gaps that may have contributed to the failure.
Journal Article > Review
Wu AW, Kavanagh KT, Pronovost PJ, Bates DW. J Patient Saf. 2014;10:181-185.
In light of an unreported conflict of interest that might have affected recommendations for chlorhexidine use to reduce risk of central line–associated infections, this review examines articles written or coauthored by Dr. Charles Denham to determine whether undeclared conflicts of interest could have influenced conclusions, selections, and recommendations in published research. The authors emphasize the need to identify and address conflicts of interest and outline strategies to reduce risk of undisclosed conflicts which may in turn affect validity of published evidence.
Stock S, Putnam J, Carroll J, Pham S. NBC Bay Area. November 19, 2014.
Hospital reporting of errors in the United States has been suboptimal. This news video investigates the effectiveness of a state reporting initiative in California. Although hospitals have reported 6282 adverse events to the state in 4 years, patient safety experts suggest that those results do not reliably represent all the incidents that should have been submitted.